ATS - pediatric emergencies

Emergency Medical Technician
20 – Pediatric Emergencies
© 2014
Slide 2

© 2014
• Responding to a pediatric emergency
can be a very emotional situation
• Emergencies involving children are
challenging because of the
developmental, medical and physical
differences between children and
adults
• Knowing how to modify your
assessment and treatments will help
you provide the best care
Slide 3

© 2014
1. Pediatric Assessment Techniques
2. Respiratory Emergencies
3. Transport Considerations
4. Pediatric Trauma Patients
Slide 4

© 2014
Slide 5

© 2014
Slide 6
• Pediatric patients differ
in age and abilities
• Adapt your assessment
and care based on the
age of the patient
• For children too young
or shy to speak, obtain
history information
from either their:
– Caregivers
– Family

© 2014
• Some children want a
parent to hold or
comfort them when
they are:
– Sick
– Injured
• Involving the parent in
your assessment can
provide reassurance for
both:
– Parent
– Child
Slide 7

© 2014
• Blood and pain can be
very frightening to
pediatric patients
• Some associate their
illness or injury as
punishment for being
bad
• Providing emotional
support is essential to
keeping children and
their caregivers calm
during an emergency
Slide 8

© 2014
Slide 9
• Many children:
– Do not like being
touched by strangers
– May be modest about
clothing removal
• Being friendly and
respectful of his or her
personal space can help
build the child’s trust

© 2014
• Older children and
adolescents often want
to be treated as adults
• Important to recognize
when a pediatric patient
is old enough to answer
questions about his or
her illness or injury
Slide 10

© 2014
• The PAT is an
assessment method
used to visually assess
a child before physical
contact
• A quick evaluation
includes observing:
– General appearance
– Work of breathing
– Circulation to the skin
Slide 11

© 2014
• The child's general
appearance is the most
important factor when
assessing the severity
of illness or injury
Slide 12

© 2014
• The mnemonic TICLS “tickles” can help you
remember the most important points to
observe in a child’s appearance
• These include:
– Tone
– Interactiveness or irritability
– Consolability
– Look
– Speech
Slide 13

© 2014
• Tone:
– Observe patient
movement, limpness
and listlessness
Slide 14

© 2014
• Interactiveness/
Irritability
– Note if the child is
alert, engaged and
interested
Slide 15

© 2014
• Consolability:
– Note if the child is
consolable
Slide 16

© 2014
• Assess “Look” by noting
if the child fixes her
gaze on a face or has a
blank stare
Slide 17

© 2014
• Observe “Speech,”
notice talking or crying
loudly or if his voice is
weak, muffled or hoarse
Slide 18

© 2014
• The use of the “TICLES”
mnemonic to assess for
“appearance” will allow
you to better detect
subtle abnormalities in
the patient
• Remember that
appearance alone is not
conclusive
• You must also assess
the other sides of the
triangle
Slide 19

© 2014
• The work of breathing is
a quick indicator of the
effort that the child is
making to compensate
for any difficulties in
oxygenation and
ventilation
Slide 20

© 2014
• Observe for obvious
signs of breathing
distress:
– Tripod position
– Retraction of the chest
muscles
– “See-saw” breathing
– Nasal flaring
• Listen for abnormal
sounds:
– Grunting
– Wheezing
– Stridor
Slide 21

© 2014
• Be aware that
respiratory rates are
higher in children and
infants
• The smaller the child,
the higher the rate
Slide 22

© 2014
• The third side of the
Pediatric Assessment
Triangle focuses on
circulation to the skin
Slide 23

© 2014
• This assessment can
help to determine the
adequacy of cardiac
output and perfusion of
vital organs
• Notice whether the
patient’s skin is pale,
mottled or cyanotic
Slide 24

© 2014
• If the child is
responsive and is not
critically ill or injured,
try to gain her trust so
she will cooperate with
your assessment
• Approach slowly and
offer a toy to show you
are friendly
Slide 25

© 2014
• Sit at the child’s level,
smile and make eye
contact
• Talk to the child directly
Slide 26

© 2014
• Explain what you are
going to do one step at
a time before you do it
• Be honest if your
assessment may cause
pain
Slide 27

© 2014
Slide 28
• Make a priority
determination as soon
as possible regarding
transport
• A priority patient is any
patient that is at risk
for:
– Shock
– Has uncontrolled
bleeding
– Is in any type of
respiratory distress

© 2014
Slide 29
• Monitor and observe for
a decline in blood
pressure and perfusion
• Pediatric patients can
compensate for injuries
or illness for a long time
– This can suppress
obvious signs and
symptoms of shock

© 2014
• Once the compensation
mechanism fails, the
child’s condition will
deteriorate rapidly:
– This is referred to as
hypotensive, or
compensated shock
• Anticipate shock in a
child that is dehydrated
from vomiting or
diarrhea
Slide 30

© 2014
• Obtain a patient history
using the “SAMPLE”
mnemonic prior to or
during your physical
exam if the nature of
the call involves illness
Slide 31

© 2014
• Conduct your physical
exam based on the
nature of illness or
mechanism of injury,
just as you would for an
adult patient
Slide 32

© 2014
• Be cautious when
assessing the head of
infants and children
under 18 months old
– Fontanels, commonly
known as “soft spots”
Slide 33

© 2014
• If the child shows fear
or anxiety, perform the
exam from toe to head
to help him adjust to
you
Slide 34

© 2014
• Only lift or remove
clothing if it is
necessary for your
exam and replace it
when you are finished
with the area
• When obtaining vital
signs, keep in mind that
pulse rates are higher in
children
Slide 35

© 2014
Slide 36
• The pulse should be
strong and regular
• The skin should be
warm and dry to the
touch

© 2014
Slide 37
• The use of pulse
oximetry is
recommended with
pediatric patients but
should only be used to
note trends in the
patient’s condition
• Consider the entire
patient presentation
when performing the
assessment and
providing care

© 2014
• Check the capillary refill
by pressing gently on
the:
– Hand
– Foot
– Forearm
– Lower leg
• The capillaries should
refill within two
seconds
Slide 38

© 2014
• Blood pressure readings
can be challenging to
obtain on young children
• If you don’t have a
pediatric-size cuff use:
– What you have
– Where it fits
• The blood pressure can be
taken on the:
– Upper arm
– Lower arm
– Thigh
Slide 39

© 2014
• Blood pressures will
vary with age
• Low blood pressure
indicates hypotension,
however a normal blood
pressure is often found
in children with
compensated shock
Slide 40

© 2014
• To estimate the upper
median of a normal
systolic blood pressure
of a child that is
between 1 and 10 years
of age:
– Take a median of 70
– Multiply the child’s age
times 2 and add the
numbers together
Slide 41

© 2014
Slide 42
• Keep in mind that blood
pressures in children
under the age of 3 are
often misleading or
inaccurate
• In these patients you will:
– Rely on the quality and
rate of the pulse
– Observe the skin signs
capillary refill
– Observe mental status
to help assess
cardiovascular status

© 2014
Slide 43

© 2014
• Infants and children are prone to
respiratory emergencies because of
several anatomical factors
• During normal respirations:
– You will observe more respiratory
action in the abdomen than the chest
– Infants and children tend to breathe
from the diaphragm
Slide 44

© 2014
• Infants and children
differ from adults:
– Airways are narrower
and softer
– Tongues take up more
space in the mouth,
contributing to airway
obstructions
Slide 45

© 2014
• Infants and children can have
difficulty clearing airway obstructions
because they do not have fully
developed:
– Lungs
– Chest walls
– Muscles in the neck
Slide 46

© 2014
• When the child is in
respiratory distress:
– Chest movement and
the use of the
accessory muscles will
become more obvious
Slide 47

© 2014
• Asthma:
– Airway spasms or
constricts
– Can be life threatening
• Colds
• Respiratory infections
such as:
– Croup
– Epiglottitis
Slide 48

© 2014
• Noisy Breathing
• Exhaling With Abnormal
Effort
• Fast / Slow Breathing
• Accessory Muscles Use
• Head Bobbing
• “See-Saw” Respirations
• Tripod Position
• Drooling
• Nasal Flaring
Slide 49

© 2014
• Cyanosis
• Slow capillary refill
• Slow heart rate
• Altered mental status
• Decreased respiratory
rate
Slide 50

© 2014
• Number one priority with
pediatric patients is to
ensure a patent airway at
all times
• Consider any airway or
breathing problems to be
life threatening
• Prepare for immediate
transport to an
appropriate facility
Slide 51

© 2014
• Provide high-
concentration oxygen
by pediatric
nonrebreather mask if
permitted by your local
protocol
• If the child feels
suffocated by an oxygen
mask, use the “blow-
by” technique
Slide 52

© 2014
• Hold the mask about
2” (5 cm) away from
the child’s face
• Tell the child to breathe
in normally
• But to blow out
forcefully as if they
were blowing up a
balloon
• Show the child by
breathing in and out
with him or her
Slide 53

© 2014
Slide 54
• Be aware that children
under the age of 6 have
a proportionately larger
and heavier head
– May cause the airway
to close when the child
is lying on his back
• Place a folded towel
under the child’s
shoulders to keep the
neck in a neutral
position

© 2014
• You must use positive-
pressure ventilation if
the child is apneic or if
the patient has an
inadequate respiratory
rate or tidal volume
Slide 55

© 2014
• For both infants and
young children, use a
pediatric bag mask
device with a volume
not to exceed 450 to
500 milliliters
• Delivered breaths
should just achieve
chest rise with each
inspiration
Slide 56

© 2014
• Attach an oxygen
reservoir to the bag and
maintain an oxygen flow
of:
– 10-15 lpm into a
pediatric bag
– At least 15 lpm into an
adult-sized bag
Slide 57

© 2014
• Older children or
adolescents may
require an adult-sized
bag mask device of
1000 milliliters to
achieve adequate chest
rise
Slide 58

© 2014
Slide 59
• For children age 1 until
puberty, deliver breaths
at a rate of 1 breath
every 3 to 5 seconds
(12 to 20 bpm)
• Breaths should be
sufficient to make the
chest rise visibly

© 2014
• If air does not enter
freely during
ventilation, reposition
the head and try again
• If the airway still will
not open, suspect an
airway obstruction
Slide 60

© 2014
• For children who have
reached puberty:
– Deliver breaths at a
rate of 1 breath every
5 to 6 seconds (10 to
12 bpm)
• Chest rise should be
visible
• Monitor the patient to
make sure ventilation is
adequate
Slide 61

© 2014
• Stand behind the
patient
• Reach around and
locate the navel
• With the other hand
make a fist and place it
just above the navel
• Grasp your fist with the
other hand
• Pull in and up with
swift, firm thrusts
Slide 62

© 2014
• Watch and listen for the
child to cough or speak
to determine if the
object has been cleared
Slide 63

© 2014
• Position the infant over
the length of your arm
face down
• Support the head with
your hand placed
around the jaw
• Keep the head lower
than the trunk
• Support your forearm
on your thigh
Slide 64

© 2014
Slide 65
• Deliver 5 back blows
between the infant’s
shoulder blades using the
heel of your other hand
• Turn the infant over
between your arms and
deliver 5 chest thrusts
• Continue back blows and
chest thrusts if the infant
is responsive and the
airway is still obstructed

© 2014
• If the infant or child
loses consciousness,
immediately begin CPR
• After 30 compressions,
assess the airway for an
obstruction
• Perform a finger sweep
by using your little
finger to remove any
airway obstructions you
can see
Slide 66

© 2014
• Try ventilating again
• Begin CPR appropriate
to the size of the child if
there is no sign of an
airway obstruction and
no pulse
Slide 67

© 2014
• Respiratory arrest is the
most common precursor
to cardiac arrest in
pediatric patients
• You must act
immediately to prevent
a respiratory
emergency from
becoming a
cardiorespiratory
emergency
Slide 68

© 2014
• If the infant or child
should experience an
unwitnessed or sudden
cardiopulmonary arrest,
the resuscitation
sequence is now “C-A-
B” rather than “A-B-C”
Slide 69

© 2014
Slide 70

© 2014
• To safely transport a
child that is ill or injured,
you will need to take into
consideration several
factors
• First:
– Decide what the best
position and placement
of the child will be in the
ambulance
– This will be determined
by what treatments or
monitoring you
anticipate performing
while enroute
Slide 71

© 2014
• If the patient is:
– Stable
– Weighs less than 40 lbs
(18 kg)
– No interventions are
anticipated:
 It may be preferable to
transport an infant or
child in her own car
seat
• Transporting a child in a
familiar car seat can be
comforting during a
unusual or scary event
Slide 72

© 2014
• Your protocols will
direct the situations
that are acceptable to
transport using the
child’s own car seat
• The NHTSA also makes
recommendations for
the use of a child's CRS,
for transport following
a minor vehicle collision
Slide 73

© 2014
The National Highway Traffic Safety
Association criteria:
• The vehicle was able to be driven away
from the crash site
• The vehicle door nearest the child’s seat
was undamaged
• There were no injuries to any vehicle
occupants
• The airbags, if present, did not deploy
• There is no visible damage to the car seat
Slide 74

© 2014
• If your protocols permit
the use of a child’s own
CRS, inspect it for
damage
• Then properly secure it
to the ambulance
Slide 75

© 2014
Slide 76
• Secure the car seat
using the existing
straps on the cot and
belt pathways
provided on the CRS
• If the child is:
– Less than 40lbs
(18kg)
– In a rear-facing car
seat:
 Place the CRS
against the back
of the cot

© 2014
Slide 77
• Adjust the car seat
harness:
– To be at or below the
shoulders of the
patient
– Then connect the
harness and pull it
snug
• Place the harness clip
at the level of the
patient’s armpits

© 2014
• If the patient is:
– Over 40lbs (18 kg)
– You may choose to
secure the child to the
stretcher in a seated
position without a car
seat
Slide 78

© 2014
• You can use:
– The existing straps on
the gurney and adjust
and size them properly
to secure the child
– Use a restraint system
designed for pediatric
patients
Slide 79

© 2014
Slide 80
• It may be recommended
to place the child in a
supine position
– If the patient has
immediate or
anticipated
interventions other
than oxygen or simple
wound care

© 2014
• Pediatric patients can
sustain a neck injury in
vehicle collisions even
when properly secured
in a car seat
• In some situations, if
the car seat is not
damaged, it may be
recommended to leave
the child in the CRS and
immobilize the patient
in place
Slide 81

© 2014
Slide 82
• To immobilize a child in
a car seat:
– Immediately provide
manual cervical spine
stabilization
– Quickly assess for
other injuries
– Place an appropriately
sized cervical collar on
the patient
– Place a small blanket
or towel on the
patient’s lap
– Secure the pelvic area
to the seat using tape
or straps

© 2014
Slide 83
– Place rolled towels on
both sides of the head
to fill voids between
the head and the seat
– Secure the head by
taping across the
forehead
– Carry the immobilized
patient to the
ambulance
– Strap patient to
stretcher in an upright
position

© 2014
• If the child requires a
backboard and a
pediatric immobilization
device is not available,
you will need to pad the
board to maintain the
spine in a neutral in-line
position
Slide 84

© 2014
• Place an 1” to 1½” (2-
4 cm) of padding
beneath shoulders and
back
– Making head level with
the occipital region of
the head
• The padding should
extend from the
shoulders to the pelvis
Slide 85

© 2014
Slide 86
• Position the patient so
you can appropriately
secure to the backboard
• Then secure the board
to the stretcher with 3
horizontal restraints:
– Across the chest
– At the waist
– At the knees

© 2014
• Place vertical restraints
over each shoulder
• You may also consider
securing the foot end of
the backboard to the
stretcher to prevent
forward movement
Slide 87

© 2014
• Immobilizing and
treating pediatric
patients can be
challenging
• Infants and children
should always be
restrained, and never
be held in the arms or
lap during transport
Slide 88

© 2014
Slide 89
• If your protocols permit, it
is helpful to have the
parent or caregiver
accompany the child in the
ambulance
• This can help to minimize
distress and provide
comfort
• As with any passenger,
regardless of where she
sits:
– Should be safely secured
with a seatbelt

© 2014
• Trauma is the leading
cause of death in
pediatric patients:
– Their bodies are
smaller and more
sensitive than an
adult’s
– They often don’t
recognize risks or react
to them in time
– Blunt trauma is the
most common injury in
children
Slide 91

© 2014
• Head is larger and
heavier in infants and
small children so they
are more likely to:
– Land head-first in a fall
– Propel head-first if
unrestrained in a
vehicle collision
Slide 92

© 2014
• Children have more
elastic chests than
adults:
– Bones in the chest are
less likely to break in a
crushing mechanism of
injury
– Offers less protection
to the vital organs
Slide 93

© 2014
• Abdominal injuries are
especially harmful in
children:
– Their muscles are not
as developed as an
adult’s
– Their organs take up
more space in the
abdomen
• Trauma to the pelvic
cavity can also cause a
lot of bleeding
Slide 94

© 2014
Slide 95
• The smaller the patient,
the less blood they can
afford to lose:
– Newborn baby’s blood
volume is less than:
 12 ounces
 A can of soda
– An 8-year-old’s blood
volume is about:
 ½ gallon
 About a 2-liter bottle of
soda

© 2014
• To manage a pediatric
trauma patient:
– Assess and manage the
ABCs
– Treat any immediate life-
threatening conditions
– Provide and maintain
stabilization of the head
and spine when trauma is
suspected
– Perform a rapid trauma
exam
– Look for less obvious or
hidden injuries
Slide 96

© 2014
• Provide oxygen by
nonrebreather mask
– Or according to your local
protocols
– Assist in ventilations
using a bag-valve device
if necessary
• Control any bleeding and
treat for shock
• Keep warm and place a
blanket underneath when
possible
– Children have a larger
skin surface area in
proportion to their body
mass, they lose heat more
quickly than adults
Slide 97

© 2014
• When performing your
physical assessment or
obtaining a patient
history:
– Keep in mind that
children may not fully
communicate the
nature of the incident
or injuries
Slide 98

© 2014
• Because children may
not display early or
obvious signs of injury:
– Try to reconstruct the
event to determine
what injuries may be
likely
• Continue to provide
reassurance
• Monitor the vital signs
during transport
Slide 99

© 2014
• Whenever you treat a
pediatric trauma
patient:
– Consider the possibility
that abuse or neglect
could be a factor
Slide 100

© 2014
• Observe the parent or
caregiver’s interaction
with the child:
– Do not offer any
judgment of the
caregiver
– Just note any signs of
abuse or neglect
Slide 102

© 2014
• Familiarize yourself
with your local
requirements in regards
to reporting suspected
cases of abuse or
neglect
Slide 103

© 2014
• Pediatric Assessment Techniques
• Respiratory Emergencies
• Transport Considerations
• Pediatric Trauma Patients
Slide 105

© 2014
• Although many of the assessment and
care techniques for adults are often
the same for children its important to
be able to modify techniques based on
a patient’s age or their physical and
emotional maturity
• Pediatric emergencies can be
challenging events
• Training and experience will help you
successfully assess and manage these
patients
Slide 106

ATS - pediatric emergencies

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